Journal of Infection and Public Health 13 (2020) 1469–1472

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Journal of Infection and Public Health

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Original Article

Severe malaria in Cameroon: Pattern of disease in children at the

Yaounde Gynaeco-Obstetric and Pediatric hospital
Andreas Chiabi a,b,∗ , Amandine Nadege M. Djimafo c , Séraphin Nguefack a,b , Evelyn Mah a,b
, Félicité Nguefack Dongmo a,b , Fru Angwafo III a,b
a
Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Cameroon
b
Yaounde Gynaeco-Obstetric and Pediatric Hospital, Cameroon
c
Institut Supérieur des Sciences de la Santé, Université des Montagnes, Cameroon

a r t i c l e i n f o a b s t r a c t

Article history: Background and objective: Malaria is the most widely spread parasitic disease in the world, especially in the
Received 26 August 2019 tropics affecting mostly children and pregnant women. In children, mostly under-fives carry the heaviest
Received in revised form burden in terms of morbidity and mortality. The aim of this study was to determine the epidemiological
28 December 2019
and clinical aspects, and outcome of children 3 months to 15 years old with severe malaria at the Yaounde
Accepted 5 February 2020
Gynaeco-Obstetric and Pediatric Hospital (YGOPH), a referral hospital in Yaounde, Cameroon.
Methods: It was a descriptive study at the general pediatric unit of the YGOPH. We enrolled all children
Keywords:
aged 3 months to 15 years admitted for severe malaria, with one or more signs of severity and confirmed
Severe malaria
children
by a Rapid Diagnostic Test (RDT) and/or thick blood smear (TBS).
Yaounde Results: Over six months, 1782 children were admitted in the unit and 466 had severe malaria giving a
Cameroon frequency of 26.10%. The mean age was 51 ± 42 months, and the sex ratio was 1.2. The highest trans-
mission rate was during the rainy season, within the months of April and May. The main symptoms on
admission were prostration, fever with body temperature ≥40 ◦ C and convulsions (61.90%, 58.00%, and
30.30% respectively). RDT was positive in 98.90% of cases and TBS was positive in 60.00%. The outcome
was favourable in 93.30% of the patients and 16 died giving a mortality rate of 3.80%.
Conclusion: Severe malaria is a public health problem affecting mostly children under five years. Proper
management consists of prompt diagnosis and early appropriate treatment. Prevention is by information,
education and communication on environmental cleanliness and the use of insecticide-treated mosquito
nets.
© 2020 The Authors. Published by Elsevier Ltd on behalf of King Saud Bin Abdulaziz University for
Health Sciences. This is an open access article under the CC BY-NC-ND license (http://creativecommons.
org/licenses/by-nc-nd/4.0/).

Introduction
Malaria is the most frequent parasitic disease in the world [1].
According to the World Health Organization (WHO), in 2015, 214
million people were affected and 438 000 died of malaria [1]. Severe
malaria is caused by Plasmodium falciparum with one or more signs
of severity or evidence of organ failure [2]. In Cameroon, malaria
continues to be a major public health problem and is the first cause
of infant-child morbidity and mortality with a mortality rate in
children under five, estimated at 40% [3,4]. The aim of this study
is to assess the clinical presentation and outcome of children with
∗ Corresponding author at: Faculty of Medicine and Biomedical Sciences, Univer-
sity of Yaounde I, Cameroon.
E-mail address: andy chiabi@yahoo.co.uk (A. Chiabi).
severe malaria, and hospitalized at the pediatric unit of the Yaounde
Gynaeco-Obstetric and Pediatric Hospital (YGOPH).
Methods
It is a descriptive study carried out over a period of 6 months at
the pediatric unit of the YGOPH from the 15th of December 2015
to the 30th of May 2016 on children aged between 3 months and
15 years, with severe malaria.
The main objective of the study was to assess the epidemiologi-
cal, clinical and biological features of severe malaria in children, and
specifically to determine the hospital frequency, assess the clin-
ical and hematological features, and factors influencing hospital
outcome.
Were enrolled in this study, children admitted for severe malaria
with one or more signs of severity, and confirmed by a rapid diag-

https://doi.org/10.1016/j.jiph.2020.02.038
1876-0341/© 2020 The Authors. Published by Elsevier Ltd on behalf of King Saud Bin Abdulaziz University for Health Sciences. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1470 A. Chiabi et al. / Journal of Infection and Public Health 13 (2020) 1469–1472

nostic test (RDT) and/or thick blood smear (TBS). We excluded Table 1
Distribution of patients according to the age groups.
children with other diseases (otitis, pneumonia and bronchopneu-
monia, meningitis, ear-nose-throat infections, etc), associated or Age range (months) Number Percentage(%)
not to malaria, and children whose parents refused to participate 3-60 323 69.91
in the study. 61-120 96 20.78
Severe malaria is defined by clinical or laboratory evidence of >120 43 9.31
vital organ dysfunction [2]. Signs of severity were those adopted Total 462 100

from WHO guidelines [2] by the Cameroon’s National Malaria Con-

trol Program [4].
The signs of severity are:
Clinical signs: consciousness disorders, convulsions, extreme
fatigue, acute respiratory distress, persistent vomiting, dehydra-
tion, severe anemia, icterus, abnormal bleeding, dark urine, no or
scanty urine, clinical acidosis, high temperature (temperature ≥40
◦ C) and shock.

Biological signs: hypoglycemia (glycemia <40 mg/dl or

glycemia <2.2 mmol/l), metabolic acidosis (serum bicarbonates
<15 mmol/l), severe anemia (Hb<5 g/dl or hematocrit <15%),
hemoglubinuria, hyperparasitemia (parasitemia >5% of red blood
cells or >250,000/␮l), serum lactate (lactate >5 mmol/l), and kidney
failure (serum creatinine >265 ␮mol/l).
In all the patients enrolled, rapid diagnostic tests and thick blood
smears were systematically done. When one or both of the tests
were positive as recommended by the WHO, the child was included Fig. 1. Distribution of the patients compared with the pluviometry.
in the study and placed on antimalarial treatment, using artesunate.
Artesunate was given at 3 mg/kg to children less than 20 kg and Table 2
2.4 mg/kg to other children at H0, H12, and H24 followed by one Distribution of patients according to the clinical features.
administration every 24 hours until the patient was able to take oral Number Percentage (%)
treatment which was an artemisinin-based combination therapy
Clinical signs
(ACT) [2].
Prostration 286 61.9
The children were hospitalized in the pediatric ward of this hos- Temperature ≥40 ◦ C 268 58.0
pital and were followed-up throughout their stay in the hospital. Convulsions 140 30.3
The variables studied were: sociodemographic (sex, age), Persistent vomiting 109 23.6
clinical features, prior home treatment (especially antimalarial Dark urine 87 18.8
Altered consciousnessa 66 14.3
treatment), paraclinical investigations (RDT, TBS, and full blood Respiratory distressb 49 10.6
count), and outcome. Control of the full blood count (FBC) and par- Behavioral disordersc 9 1.9
asitemia during hospitalization depended on the clinical evolution Abnormal bleeding 7 1.5
of the child with treatment. Physical signs
Splenomegaly 165 35.7
The RDT used in this study were the SD BIOLINE Malaria Ag Pf /
Hepatomegaly 103 22.3
Pan test, which is a qualitative rapid test for the detection of Plas- Extreme pallord 98 21.2
modium falciparum histidine - rich protein-II (Pf HRP II) and lactic Jaundice 26 5.6
dehydrogenase (pLDH) for the other Plasmodium species in man. Dehydration 2 0.4
All these data were entered in a pretested questionnaire. Before a
stupor and coma.
starting the study we obtained authorization from the Director of b
this sign was mostly seen in extremely pale children.
c
the hospital as well as ethical clearance from the ethical committee agitation and delirium.
d
severe anemia with Hb<5 g/dl.
of the hospital. Only children whose parents gave informed written
consent were enrolled in the study. The rainfall dataset for this
study was obtained from the Meteorological Office of the Ministry Clinical findings
of Transport in Yaounde.
The most frequent signs of severity on admission were pros-
tration (61.9%), fever with a temperature ≥40 ◦ C (58.0%) and
convulsions (30.3%). The main physical signs were splenomegaly
Results (35.7%), hepatomegaly (22.3%) and pallor (21.7%). The clinical find-
ings are represented in Table 2. The mean time between the onset
Sociodemographic features of the disease and admission was 4 days (extremes 1 to 21 days).
Out of the 66 children with altered consciousness, 51 were less
During the study period, 1782 children were hospitalized in the than 5 years old and 30 (58.8%) were in stage 1 coma (Blantyre
pediatric unit and 466 were hospitalized for severe malaria, giv- score = 4).
ing a frequency of 26.15%. Four were excluded due to incomplete
information and so 462 were finally enrolled in the study. Investigations
Out of the 462 patients, 250(54.11 %) were males and 212(46.89
%) were females giving a sex ratio of 1.2. Out of the 462 children, the RDT were positive in 457 (98.9%)
Most of the children were less than 5 years (69.91 %) (Table 1). children, and the blood smears positive in 279 (60.4%) of the chil-
The mean age was 51 months (extremes 3 to 186 months). Most dren (Table 3).
cases were noted in the months of April and May, which are rainy The parasite species found on both the RDT and blood smears
months in Cameroon. The pluviometry is shown in Fig. 1. was Plasmodium falciparum (Pf).
 A. Chiabi et al. / Journal of Infection and Public Health 13 (2020) 1469–1472
Table 3
Distribution of the rapid diagnostic tests (RDT) and blood smears
RDT Blood smears
Number % Number
Positive 457 98.9 279
Negative 5 1.1 183
Total 462 100 462
The mean parasite count was 60,662 trophozoites/mm3
(extremes: 24 – 1463000 trophozoites/mm3 ).
Out of the 452 children for whom a FBC was done, 66.6% had
thrombopenia (18.1% mild, 28.8% moderate, and 19.7% severe). The
platelet counts were classified as follows - severe thrombopenia :
< 50,000/mm3 ), moderate thrombopenia : [50,000 -100,000/mm3 [,
mild: [100,000 – 150,000/mm3 [, and normal : ≥ 150,000/ mm3 . The
mean platelet count was 137366.15/mm3 .
In these patients, 21.7% had severe anemia; the anemia was
mainly microcytic with a mean hemoglobin (Hb) of 7.9 g/dl and
a mean corpuscular volume (MCV) of 69.5 fl.
Treatment
Of the 462 children enrolled in the study, 439 had received some
form of treatment before their admission. We noted that 95.00% of
the children had received treatment at home prior to admission.
Amongst the drugs taken, 50.40% took antimalarial drugs, with qui-
nine in 23.70% of the patients, and ACT in 17.80%. The antimalarial
treatment received at home, was adequate (in terms of appropri-
ateness of the drug and dose) in 53.00% of the patients.
In our patients, the antimalarial drug regimen used was arte-
sunate as recommended by the WHO in 2012 [2] and adopted by
Cameroon in 2013 [4] as the first line treatment of severe malaria.
The patients systematically received adjuvant treatments
(antipyretics, anticonvulsants, blood transfusions) when necessary.
Evolution
The mean hospital stay was 69 hours with extremes of
(1 h – 9days). A total of 431 children were discharged alive, whereas
15 were discharged against medical advice for financial reasons. We
noted 16 deaths giving a death rate of 3.8%.
Out of the 431 children who were discharged, two had neurolog-
ical complications; one had a post-malaria neurological syndrome
and the other had cortical blindness, a right hemiparesis, hypo-
tonia and aphasia. Two children (12.5 %) died in the second hour
following admission, 8 (50%) during within first 14 hours, and 14
(87.5 %) with the first 24 hours of admission. All the deaths occurred
within 40 hours of hospitalization. The overall survival rate was
96.5%. (Fig. 2).
Discussion
The frequency of severe malaria in this study was 26.15%. A sim-
ilar finding has been noted by Geleta et al in Ethiopia in 2015 who
had a frequency of 25.70% [5]. Other authors in Africa [6–9] had
lower values than ours 12.68%; 18.40%; 19.40% and 21.60% respec-
tively. Chiabi et al in 2007, had a higher frequency (29.20%) and
in the same setting [8]. This can be the result of continuous sen-
sitization on malaria prevention which has been ongoing in this
hospital. Higher incidences of 28.80% and 34.00% have also been
reported by other authors in different settings [10,11]. Despite the
fact that these studies were all carried out in sub-Saharan Africa,
the study settings differed, as well as methodologies and sample
sizes, which could explain the variations in the incidences.
1471
%
60.4
39.6
100
Fig. 2. Kaplan Meier survival curve.
The most represented age group was 3 to 60 months i.e. 69.9%
of our study population. This finding is in accordance with WHO,
which states that children less than 5 years are most vulnerable to
malaria [1]. The mean age in our study was 51 months (4.25years),
similar to the 4.1 years noted by Geleta et al in Ethiopia in 2015
[5]. Kunuanunua et al, in 2015, had a higher mean age of 8years in
the Democratic Republic of Congo [12]. There was a male predom-
inance, which has also been noted in other studies [5–12].
The frequency of the disease was closely associated with rain-
falls with most cases noted in the months of April and May which
are rainy periods in Cameroon. This observation was also noted
by Chiabi et al [7]. The female anopheles mosquito, vector of the
malaria parasite in man, is a mosquito specie which develops dur-
ing the rainy season, and lays its eggs in water pools. Rains create
a moist climate, resulting in a rapid parasitic cycle, thus increasing
malaria transmission during this period.
The criteria of severity were those adopted by the Cameroon’s
National Malaria Program [4], from WHO guidelines [2]. The most
frequent clinical findings were prostration (61.9%), fever with tem-
perature ≥40 ◦ C (58%) and convulsions (30%). Similar findings have
also been observed by other authors [5,7,13].
The RDT was positive in 98.9% of the children, and five children
had a negative RDT with a positive thick smear. Ajumobi et al [14],
Bharti et al [15] and Mohon et al [16] showed that the sensitivity
of RDT specific to Pf varies between 98-100% and the specificity
between 97-99%. The thick blood smear was positive in 279 chil-
dren (60.4%). This could be explained by the fact that most of the
children had received malaria treatment prior to admission.
Microcytic normochromic anemia was observed in 21.7% of
the patients. However, Mabiala-Babela et al, in Congo [17] noted
microcytic hypochromic malaria in 34.2% of their patients and
normocytic normochromic anemia in the remaining cases. Sev-
eral authors have noted thrombopenia in severe malaria [23–27].
Kaushik et al in India, also noted thrombopenia in severe malaria
due to Plasmodium vivax severe malaria [18]. Imbert et al in Senegal,
showed that thrombopenia was a risk factor for poor outcome [19].
Mechanisms to explain thrombopenia in malaria are multifactorial
[17,20,21]. These include coagulation abnormalities like DIC (dis-
seminated intravascular coagulation), platelet sequestration by the
spleen and destruction of platelets by macrophages, bone marrow
dysfunction, oxidative stress, anti-platelet antibodies and platelet
aggregation.
Mortality was 3.8%, and 87.5% survived within the first 24 hours
following admission. Mortality was highest in the first 24 hours.
This shows the importance of parenteral treatment with Arte-
sunate, with three doses administered within the first 24 hours.
Among the patients who were discharged, two developed neu-
1472 A. Chiabi et al. / Journal of Infection and Public Health 13 (2020) 1469–1472
rological complications: one developed post malaria neurologic
syndrome (PMNS) with hallucinations and delirium after treatment
and lasted two days. The PMNS is a rare neuropsychiatric syndrome
which can occur within two months after treated Plasmodium fal-
ciparum malaria [22,23]; the other patient had cortical blindness
with aphasia, right hemiparesis and hypotonia. The patient with
PMNS improved rapidly within 2 days, and in the other patient
the symptoms regressed slowly over a month. It has been shown
that factors like hypoglycemia, repeated convulsions, increased
intracranial pressure, hypoxia, duration and depth of coma could
influence the occurrence of neurological complications which could
be acute during hospitalization or chronic over several months fol-
lowing a malaria episode [24].
Conclusion
The main clinical features in this study were prostration (61.9%),
hyperpyrexia (58%) and convulsions (30.3%) and mortality 3.8%.
Severe malaria in children is still a very frequent disorder in our
environment affecting mostly young children under five. To reduce
morbi-mortality from this disorder, rapid diagnosis of suspected
cases should be done and appropriate recommended treatments
instituted. Most importantly emphasis should be placed on pre-
ventive measures as insecticide treated bed nets and a clean
environment.
Funding sources
No funding sources
Conflict of interest
Non declared.
Ethical approval
Ethical clearance was got from the Institutional Ethical Commit-
tee for Research in Human Sciences, No 215/CIERSH/DM/2015.
Authors’ contributions
Andreas Chiabi: conception and design of the study, Aman-
dine Nadege M. Djimafo, Evelyn Mah, Séraphin Nguefack, Félicitée
Nguefack Dongmo: acquisition, analysis and interpretation of data,
Amandine Nadege M. Djimafo, Andreas Chiabi: drafting the article,
Fru Angwafo III, Andreas Chiabi: revising it critically for important
intellectual content. All authors have read and approved the final
manuscript.
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